=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669080487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE MOUNTAIN PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2020
-----------------------------------------------------
Last Update Date | 07/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 W BAILEY BOSWELL RD
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-576-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3575 LONE STAR CIR STE 310
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76177-8908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-350-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEREMY LUSTIG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 214-335-0862
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------